An
HIV-infected
girl
with
an
abscess
at
her
l
|
Prepared by...Aurmporn Oberdorfer, MD, PhD
Virat Sirisanthana, MD |
|
Department of Pediatrics, Chiang Mai University, Thailand |
eft
arm
(Page
2/2)
|
| Differential
diagnosis |
|
1.
|
Bacterial
abscess |
|
2.
|
Abscess
from
BCG
as
an
immune
reconstitution
syndrome
|
|
| Investigations |
|
1.
|
Aspiration
at
the
abscess:
pus
and
blood
~
0.3
ml
(Figure
2).
|
|
Gram
stain:
numerous
PMN,
no
bacterial
seen |
|
AFB
stain:
positive
2+
(Figure
3) |
| 2. |
Chest
X-ray:
normal |
|
3.
|
Tuberculin
skin
test:
72
hours
later....
17
mm.
in
diameter
as
in
figure
4. |
| |
|
|
|
|
|
Figure
2:
Pus
obtained
from
needle
aspiration
|
Figure
3:
AFB
positive
from
pus
aspiration
|
|
|
|
|
Figure
4:
Tuberculin
skin
test:
indurated
17
mm.
in
diameter
|
|
| Diagnosis:
BCGitis
as
an
immune
reconstitution
syndrome
|
|
|
Discussion:
As
a
high
prevalence
of
tuberculosis
in
Thailand,
immunization
with
Bacillus
Calmette-Guerin
(BCG)
at
birth
(+
booster
at
the
age
of
6
years)
is
in
the
Thai
Expanded
Programme
on
Immunization
guidelines.
With
epidemic
of
HIV
infection,
the
policy
has
not
been
changed,
since
1)
the
vaccine
is
effective
in
preventing
tuberculosis
2)
although,
the
frequency
of
BCG-related
complications
may
be
slightly
higher
in
HIV-infected
infants
compared
with
normal
infants,
these
complications
are
usually
mild
(1-2).
In
the
highly
active
antiretroviral
therapy
(HAART)
era,
there
is
a
syndrome
called
"Immune
reconstitution
inflammatory
syndrome,
or
Immune
restoration
disease"
(3-4).
Reconstitution
of
cellular
immunity
to
mycobacterial
antigens
was
one
of
the
common
components
of
this
syndrome.
BCG
can
act
as
a
mycobacterial
antigens
as
has
been
previously
reported
in
an
infant
(5).
|
|
| Questions:
What
is
the
appropriate
management
in
this
case? |
| Answer:
The
patient
should
be
treated
with
isoniazid
and
rifampin
for
6-9
months. |
|
| Questions:
What
should
be
a
precaution
in
the
situation
when
an
HIV-infected
child
already
immunized
with
BCG
is
about
to
receive
potent
antiretroviral
therapy?
|
| Answer:
We
would
recommend
closed
observation
of
the
child
during
the
first
3
months
of
potent
antiretroviral
treatment
for
signs
of
regional
or
disseminated
BCG
infection.
If
it
occurs,
the
aspirated
specimens
should
be
examined
for
acid
fast
bacilli
organism.
If
there
are
AFB
organisms,
the
lesion(s)
is(are)
typical
of
regional
BCG
infection
and
the
other
mycobacterial
infections
could
be
clinically
excluded,
the
patient
should
be
treated
with
isoniazid
and
rifampin
for
6-9
months.
If
other
mycobacterial
infection
can
not
be
excluded
the
child
should
receive
combination
of
3
antimycobacterial
drugs,
including
isoniazid,
rifampin
and
pyrazinamide
until
the
organism
is
confirmed
as
BCG,
after
which
pyrazinamide
should
be
ceased.
Treatment
should
last
for
6-9
months.
|
|
| References: |
|
1.
|
O'Brien
KL,
Ruff
AJ,
Louis
MA,
et
al.
Bacillus
Calmette-Guirin
complications
in
children
bom
to
HIV-
1-infected
women
with
a
review
of
the
literature.
Pediatrics
1995;95:414-8
|
|
2.
|
Sirisanthana
V.
Bacille
Calmette-Guerin
(BCG)
vaccine
complications
in
HIV-infected
children.
J
Infect
Dis
Antimicrob
Agents.
1995;12:63-67.
Click
for
 pdf
file |
|
3. |
In Thai: (View,encoding,Thai-Windows) วิรัต ศิริสันธนะ. Immune Reconstitution Inflammatory Syndrome ในผู้ป่วยเอชไอวีที่ได้ยาต้านไวรัส . ทวี โชติพิทยสุนนท์, อังกูร เกิดพาณิช, รังสิมา โล่ห์เลขา, (บรรณาธิการ). Update on Pediatric Infectious Diseases 2004. dกรุงเทพฯ : บริษัท รุ่งศิลป์การพิมพ์ จำกัด 2547. p 287-93. click for  pdf file |
|
4.
|
French
MA,
Price
P,
Stone
SF.
Immune
restoration
disease
after
antiretroviral
therapy.
AIDS
2004,18:1615-27. |
|
5.
|
Sharp
MJ,
Mallon
DF.
Regional
Bacillus
Calmette-Guerin
lymphadenitis
after
initiating
antiretoriviral
therapy
in
an
infant
with
human
immunodeficiency
virus
type
1
infection.
Pediatr
Infect
Dis
J
1998;17:660-2 |
|
|
